Care Calls helps members manage chronic diseases

Program includes materials, self-monitoring tools

Using a combination of telephone calls from certified case managers, written materials, self-monitoring tools, and reminder messages to physicians, Univera Healthcare is helping members learn to monitor their chronic diseases.

The goal of the program is to support members with chronic diseases by telephone rather than providing classes or group sessions for members with diabetes, asthma, depression, and heart disease, says Jay Pomerantz, MD, vice president and chief medical officer for the Buffalo, NY-based health care plan.

Care Calls is provided as a basic level of service to all members who choose to participate.

"Since August 2001, our Care Calls program in Western New York has educated and supported more than 1,775 members with chronic diseases. It’s an excellent, hassle-free alternative to classes or group sessions," Pomerantz reports.

The program offers telephone support for members with diabetes, asthma, depression, and heart disease.

The purpose of the program is to get the members to learn to manage and monitor their own health.

The health plan sends incentives to members in the program, including scales for heart failure patients, peak flow monitors for members with asthma, a choice of glucometers for participants in the diabetes program, and medication containers for those in the depression management program.

The nurses who make the Care Calls all are registered nurses who have been certified as case managers. They have undergone extensive training on each of the four disease states and are backed up by the plan’s medical directors, who are available for consultation, adds Peggy Davis, regional director for medical benefits management, utilization management, and case management.

The nurses are cross-trained to work with members regardless of their illness.

Program promotes job satisfaction 

The program has generated a lot of job satisfaction, Davis notes. "We have a very stable team. There’s been no turnover since the inception of the program. The nurses have a lot of professional pride. They’ve worked together and seen the program grow."

When a member is identified for the program, he or she is assigned to whichever nurse is free. The nurses work with the same panel of members during the time they are in the program. The exception is that when a nurse is on vacation, her colleagues will handle her members.

"We felt that it was beneficial to develop a patient-nurse rapport," Pomerantz says.

The health plan developed a standard curriculum for each disease state with the help of its physician advisory committees.

For instance, local cardiologists helped develop the heart failure program.

"We have standard topics that are covered during the education portion. In addition, we take a look at evidence-based clinical guidelines at least yearly to make sure the education we provide remains current," Davis says.

The curriculum for each disease is divided into five modules, which the case managers cover at the pace of the member.

Members receive at least five telephone calls and as many as 10, depending on how well they were able to absorb the information, understand their disease, and start managing their own health care.

"If they continue to struggle with self management, the nurses will work with them longer," Davis says.

The health plan started its disease management efforts with a telephone program for members with congestive heart failure.

"We were looking at informed decision making and evidence-based management for the patients and how to use ongoing telephonic contact to assure adherence," Davis says.

The care managers supported the members in managing their congestive heart failure, encouraging them to watch their diet, exercise, take medications as prescribed, and weigh themselves daily.

The health plan has gradually expanded the Care Calls program to include members with diabetes, asthma, depression, coronary artery disease, and smoking cessation.

The health plan’s behavioral health staff trained the nurses on how to identify when a member is ready to change.

"People can circle up and down in readiness for change. We gave the nurses dedicated training on the Prochaska model and how to identify at which stage the member is," Davis says.

Patients are identified by claims activities, referrals from physicians, self-referrals, and with a health risk assessment tool for the plan’s Medicare patients.

Univera Healthcare’s on-site nurses, who perform utilization management and concurrent review in major hospitals, frequently refer members to the program when they encounter someone with a chronic disease either in the hospital or emergency departments.

"The on-site nurses visit all of the Univera Healthcare members in the hospital and discuss programs and services, such as Care Calls, that are available to them. If the members are not in a hospital where our nurses are located, we tell them about the Care Calls program when we make post-discharge calls to make sure the member understands the discharge instructions and makes a follow-up appointment with their physician," Davis says.

Once the members are identified, the Care Calls nurses try to reach them by telephone. They call three times on different days and at different times of day. If they are unable to reach the member, they send him or her an introductory letter, inviting the member to join the program.

The Care Calls program is an opt-in program in which many members choose to participate.

"When we get into coaching and lifestyle modifications, some people no longer want to participate. For instance, if they aren’t ready to stop smoking, they may exit from the program," Davis says.

"We have a high participation rate at least partly because the program is nonthreatening. The nurses are there to be advisory and helpful, rather than being critical and judgmental," says Pomerantz.

Follow-up is driven by the severity of the members’ conditions, how stable or unstable they are, and where they are in treatment. If a member experiences an exacerbation, the nurses will call more frequently.

For instance, when a member is newly diagnosed with depression and just starting on medication, the nurses will call him at least weekly, working on medication compliance and supporting him during the early days of his treatment.

"We want to provide motivation and reinforcement in the time when they haven’t yet seen the benefits of the medication," Davis says.

Educating members 

A congestive heart failure patient who is just out of the hospital will receive frequent calls as well, while a member whose condition is stable and who is able to self-manage may get a phone call as infrequently as every three months.

The nurses educate all the members they work with about Univera Healthcare’s Member Rewards discount program, which offers discounts on programs and services that range from health club memberships to Lasik eye procedures.

The health plan’s disease management program includes working with the members’ primary care physicians and specialists to make sure the members receive recommended tests and screenings and assure the continuation of long-term interventions.

For instance, the physicians receive patient management reminders at least quarterly. In many cases, the physicians’ office management system interfaces with Univera Healthcare’s computer system, allowing the health plan to send patient reminders overnight before the patient’s appointment, prompting the physician on what kind of tests or examinations the member needs.

"The physicians love it. It’s voluntary, and every office we’ve offered it to has elected to enroll. It saves staff time going to chart to find out when a patient had a colonoscopy or an eye examination," Pomerantz says.

The health plan sends the physicians reminders of the medications the patient takes, any emergency department visits, smoking cessation classes, when the last labs were done, and what the lab values were.